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08 Mistake Proofing v20130529
08 Mistake Proofing v20130529
GPS
MUDA MUDA
3P
RPIW Kaizen Kaikuku Prod
Module 8
Prep
7 Flows 7 Flows
Factory Product/Patient Quantity Analysis Medicine
• Sweeping 7
• Sorting
4 No’s
• Simplifying 5S • Standardizing
• Self Discipline
Wastes
Mistake Proofing
Purpose:
Mistake proofing prevents mistakes before they create
defects.
Why Do Mistake Proofing?
Eliminate Rework.
Improve Quality.
Reduce Cost.
Improve Lead Time (especially in relation to the
predictability of cycle times).
Patient Satisfaction.
Zero Quality Control (end of line inspection).
Improve Patient Safety.
Improve Staff Engagement and Morale.
08 Mistake Proofing v20130529 4 ©1996-2013, John Black and Associates LLC
Licensed Materials – USA Copyright Laws Apply
Mod 8 – Mistake Proofing
Recognizing
Mistake-Prone Situations
A mistake-prone situation exists when it is possible to create an error
while doing a task, procedure, or providing a service because the
process being used is unreliable or unstable.
Some common mistake-prone situations.
Critical clinical protocol or Revisions or changes.
procedure requirements. Short-cuts and workarounds.
Inadequately maintained
New products, processes or
instruments and equipment.
people.
Ineffective standard procedures
and processes. Multiple handovers.
Infrequent occurrence of a task Multiple suppliers.
or process. Same information in numerous
Multiple parts, processes, or places.
steps.
Repetitive, fast-paced
Poor environmental conditions.
operations
08 Mistake Proofing v20130529 5 ©1996-2013, John Black and Associates LLC
Licensed Materials – USA Copyright Laws Apply
Mod 8 – Mistake Proofing
Root Cause
It is important to find and eliminate the root
cause, not the symptoms, so the problem will
not occur again.
Once the root cause is found, then the corrective
action must be taken to prevent the error from
occurring again. Otherwise, we create a defect loop
where the error occurs time and again, generating
defect after defect.
AN ERROR
The defect is DOES THE
TAKES PLACE !
corrected NO CORRECTIVE
(CAUSE) ACTION ALTER THE
PROCESS OR THE
DESIGN TO PREVENT
RECURRENCE
OF THE
DEFECT?
The defect is
A defect occurs
identified and YES
as a result
documented
DEFECT IS
ELIMINATED!
Poka-yoke Devices in
Healthcare
From Mistake-Proofing the Design of Health Care Processes, Agency for
Healthcare Research and Quality (AHRQ), May 2007.
www.ahrq.gov
Mistake-Proofing
How to Get to Zero Defects
1 2 3 4 5
Perfection is so hard…
How about something close?
Another view…
Zero-defects is
possible
Parachute Packers
Most of us are taught that
nothing is perfect.
In WWII, aircraft crewmen
were informed that their
parachute failure rate was
3%.
The “Zero Defects” goal was
reached when the parachute
packers were told that they
would test the parachutes
they packed by jumping from
the planes themselves.
Shigeo Shingo
Industrial management innovator.
What is Inspection?
One of the basic features of
flow.
A way to protect the
patient from receiving
a defective product.
Waste - if used incorrectly.
Mistake OR Defect
Root cause is Root cause is
obvious. obscure.
Remedy is easy, Remedy is hard,
immediate. delayed.
1 2 3
Successive check.
Next process checks prior process work.
Flaws are sent back to be fixed.
1 2 3
Good Defective
Process Mistake
Product Product
08 Mistake Proofing v20130529 38 ©1996-2013, John Black and Associates LLC
Licensed Materials – USA Copyright Laws Apply
Used with permission © Virginia Mason Medical Center
Mod 8 – Mistake Proofing
Level 1:
Customer Inspects and Finds Defect
(OIG, DOH, Malpractice Suit)
Feedback
Suppliers 1 2 3 4 5 Customers
Mistake Customer
Occurs finds defect
08 Mistake Proofing v20130529 41 ©1996-2013, John Black and Associates LLC
Licensed Materials – USA Copyright Laws Apply
Mod 8 – Mistake Proofing
Level 2:
Company Inspects at End of Process
(QA, Audit, Narcotic Count)
Feedback
Suppliers 1 2 3 4 5 Customers
Mistake Inspector
Occurs finds defect
08 Mistake Proofing v20130529 42 ©1996-2013, John Black and Associates LLC
Licensed Materials – USA Copyright Laws Apply
Mod 8 – Mistake Proofing
Level 3:
Work Unit Inspects and Corrects
(Needle and Sponge Count)
Feedback
Suppliers 1 2 3 4 5 Customers
Mistake Worker
Occurs finds defect
08 Mistake Proofing v20130529 43 ©1996-2013, John Black and Associates LLC
Licensed Materials – USA Copyright Laws Apply
Mod 8 – Mistake Proofing
Level 4:
Self-Inspection and Correction
(Patient ID, Surgery Site Check)
Suppliers 1 2 3 4 5 Customers
Mistake detected
and corrected
08 Mistake Proofing v20130529 44 ©1996-2013, John Black and Associates LLC
Licensed Materials – USA Copyright Laws Apply
Mod 8 – Mistake Proofing
Level 5:
Process Redesign to Eliminate Mistakes
(Pin index, CPOE)
Suppliers 1 2 3 4 5 Customers
Level 5 Inspection
08 Mistake Proofing v20130529 47 ©1996-2013, John Black and Associates LLC
Licensed Materials – USA Copyright Laws Apply
Mod 8 – Mistake Proofing
Level 5 Inspection
Cath Lab: Imaging equipment has built-in stop to
avoid crushing the patient.
08 Mistake Proofing v20130529 49 ©1996-2013, John Black and Associates LLC
Licensed Materials – USA Copyright Laws Apply
Mod 8 – Mistake Proofing
Used with permission / Seattle Children’s Bellevue Clinic and Surgery Center
Visual reminder to perform a final Self Check for specimen labeling prior to
sending to the lab Used with permission of Saskatchewan Ministry of Health
Mistake-Proofing Summary
Defects are caused by inappropriate procedures or
standards, excessive variability, damaged or excessively
variable material, worn machine parts, or human
mistakes.
The three main methods for mistake-proofing are
mechanisms/devices, inspection and visual control.
Mistake-proofing systems need not be fancy or
expensive. Many are quite simple and inexpensive.
The people who know the equipment, machines and
processes best suggested many of the solutions.